13 Implementation and audit

13.1 Local implementation

Implementation of national clinical guidelines is the responsibility of each NHS Board and is an essential part of clinical governance. It is acknowledged that every Board cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

13.1 SMC and NICE guidance

The Scottish Medicines Consortium has issued advice on the use of nicotinic acid (February 2006).295 Assessments on a number of statins, angiotensin receptor blockers, beta blockers and direct thrombin inhibitors are also published. Further details are available from www. scottishmedicines.org.uk.

The following reports have been approved by NHS Quality Improvement Scotland:

13.3 Key points for audit

The National Clinical Datasets Development Programme and ISD Scotland are working to develop national standard datasets for implementation in IT systems supporting patient care. The following clinical datasets have been developed and are available at www.datadictionary.scot.nhs.uk

CHD core

acute coronary syndromes

cardiac rehabilitation

heart failure

electrophysiology

The CHD and Stroke Programme is setting up working groups to develop methods and coding definitions to support the monitoring of the new SIGN guidelines from new datasets and existing data collections. Where there are gaps in the data ISD Scotland will work to support the necessary information collection.

13.4 Recommendations for research

Risk estimation

What organisational and resource changes are required within primary care to deliver a comprehensive service for CVD risk assessment, modification and follow up?

What would be an ideal balance of general practitioner/practice nurse and administration resource? Should these services be provided within structured clinics within primary care or should they be delivered within normal surgeries.

Physical activity and exercise

The dose response of exercise for reducing CVD risk is well recognised. Further questions following from this are:

Does this dose response apply to individual risk factors, for example, blood pressure?

Is there a minimum cutoff threshold for frequency, intensity or duration of exercise below which the dose-response effect no longer applies, or below which a minimum effective response is seen?

Independent studies of the effectiveness of bupropion for smoking cessation in people with schizophrenia are needed.

Alcohol

What are the effects of varying doses of alcohol on the symptoms of CHD in those with established CHD?

How much do the confounding factors identified in previously conducted observational studies of alcohol consumption impact on the reported findings?

Pharmacological intervention

What is the most effective treatment of resistant hypertension (patients not at target despite triple therapy)?

Large trials of lipid lowering using multiple agents compared to raising doses of statins are required.

Well designed RCTs and cohort studies are required to investigate the effect of titrating lipid therapy based on proposed LDL cholesterol targets, controlling for pre-event values of known cardiovascular risk factors, treatment status (placebo vs statin, assessing interactions with deviations from arm of randomisation), and accounting for pill adherence.

What is the risk/benefit balance for intensive lipid lowering in asymptomatic individuals at high risk of CVD?

Qualitative evidence on the perceptions of patients currently taking statins on the perceived benefits and harms of adhering to therapy is lacking.

More evidence is needed to confirm the role of aspirin for patients with diabetes.

Diet

Does the effect of fish oil fatty acids on CHD risk differ between patients with acute coronary syndromes and patients with stable CHD?

Does the advice of dietitians or doctors more effectively reduce the risk of CVD?

Other

What is the value of sustained weight loss in lowering blood pressure?